Attachment integrated claims system and operating method therefor

ABSTRACT

A digital device operatively coupled to a computer network including first and second networked components receives unitary data stream having N fields of data and an associated Nth field label, and distributes the contents of each of the N fields to one of the first and second networked devices in response to the N field labels included in the unitary data stream, where N is a positive integer. A method for operating the digital device is also described.

CROSS REFERENCE TO RELATED APPLICATIONS

[0001] This is a continuation of application Ser. No. 10/036,342, whichwas filed on Jan. 7, 2002, which is a continuation of application Ser.No. 09/592,256, which was filed on Jun. 12, 2000 and which issued asU.S. Pat. No. 6,338,093 on Jan. 8, 2002, which is continuation ofapplication Ser. No. 09/232,805, which was filed on Jan. 19, 1999 andissued on Jun. 13, 2000 as U.S. Pat. No. 6,076,066, which is acontinuation of application Ser. No. 08/824,010, which was filed on Mar.25, 1997, and issued as U.S. Pat. No. 6,003,007 on Dec. 14, 1999. All ofthe above-identified applications claim priority from ProvisionalApplication No. 60/014,427, which was filed on Mar. 28, 1996.

BACKGROUND OF THE INVENTION

[0002] The present invention relates generally to an attachmentintegrated claims (AIC) system for preparing and processing forms withintegrated attachments. More specifically, the present invention relatesto an AIC system for preparing and processing digital insurance claimsincluding Prior Approval claim (PAC) Applications containing both a textform and an integrated digitized attachment. A method of operating atotally digital AIC system is also disclosed.

[0003] High administrative costs for filing and processing healthinsurance claims have been the bane of the health insurance industryfrom its inception. Over the years, many attempts have been made todevelop a faster and more cost effective claims processing system. Threestages in this development effort are described in the followingcorrespondingly numbered paragraphs.

[0004] (1) The original system involved hard copy paper claims only,with transmission and all processing done manually. Originally, aninsurance claim was filed by the patient or the health care providerfilling out a paper form. The completed paper form was then mailed tothe insurance company. At the insurance company, the paper claim formwent through a series of administrative steps, all the time remaining asa hard copy paper object. When a decision was made, the decision waswritten up and archived with the claim form; a hard copy was also sentto the patient and/or provider along with the payment.

[0005] (2) The first significant advancement resulted from theintroduction of the mainframe computer. This allowed for electronicprocessing within a given insurance company, i.e., once the claim was onthe computer inside the company, the paper form could be dispensed with.Computerization is a highly effective way of reducing administrativeoverhead in claims processing.

[0006] Thus, mainframe computers were purchased and installed internallyat the insurance companies. Since these computers were intended forinternal use only, each company thought only of its own needs and hadits claims management software customized. While the claims managementsoftware for a number of insurance companies would be written in thesame high-level programming language, e.g., COBOL, the similaritybetween software programs often ended there. There were many virtues tothese early systems, primarily with respect to decreased administrativecosts, but a major drawback was that the data for each “paper” claim hadto be entered into the computer to form an electronic claim. Thisnecessitated the manual transcription of exactly the same informationthat had been handwritten into the original paper claim before it wassent to the insurance company.

[0007] (3) The next advancement was the electronic filing of claimforms. This was made possible by the introduction of the personalcomputer and modem into the provider's office. The main purpose of thisstage was to eliminate the manual re-entry of information into theinsurance company mainframe.

[0008] The basic idea was to have the providers fill out an electronicclaim form, instead of a paper claim form. This electronic form, whichwould be stored in the memory of their PCs, would then be transmitted,as a computer file, to the insurance company. It could then beintegrated directly into the electronic claims processing system withoutthe manual re-entry of data. Thus, the technology existed to produce asystem that computerized the overall filing and processing of theinsurance claim from the point of entry, the provider's office, to thefinal report of the claims adjuster.

[0009] Although the idea was straightforward, implementation was not.Two basic problems had to be overcome in order to create a viablesystem. First, the information contained in the electronic claim formhad to be integrated into the claims processing software at theinsurance company. Second, a majority of providers have to be able tointerface with a majority of insurance companies, i.e., insurancecompany mainframe computers. However, because of the way computers hadentered the insurance industry originally (stage #2), there was noindustry-wide standard, i.e., the legacy mainframe computers of thedifferent insurance companies were incompatible. This was true both withrespect to the type of software used and with respect to the informationthat each company required on its claim form.

[0010] One attempt to deal with these problems was the creation, by aconsortium of insurance companies, of the National ElectronicInformation Corporation (NEIC). NEIC's basic function is that of aclearinghouse. It interfaces between the insurance companies and theservice providers. It also establishes rigid standards that must be metin order to transmit an electronic claim form to an insurance company.In practice, the service provider sends an electronic claim to a vendor,who performs a service such as screening of the form. The vendor thentransmits the form to NEIC, which then retransmits it to the patient'sinsurance company. Since it is a computer file, the information in theelectronic claim form can then be entered directly into the company'smainframe claims processing system, without the manual re-entry of data,and then processed.

[0011] Thus, a coherent system was created that allows for theelectronic filing, transmission, and processing of insurance claims.This system is employed by thousands of providers and hundreds ofinsurance companies.

[0012] NEIC was designed to act as a clearinghouse for claims that are100% text and that conform to very restrictive formats. For claims thatmeet these conditions it functions well, resulting in substantialsavings on administrative costs for the insurance companies. It has beenestimated that going to this third stage system results in savings of asmuch as 60% in claims processing costs.

[0013] But there are many claims that do not meet these conditions.These would include claims that require additional text information thatdoesn't fit into the prescribed format and/or claims that requirenon-text information. In general, these are called “claims withattachments.” “Attachments” are any additional information that must besent with the “standard text claim form.” This could include: pictures,graphs, additional text not allowed on the standard claim form, soundrecordings, etc.

[0014] An example of such a claim would be the PAC (Prior Approvalclaim), which may be alternately denoted as a “Pretreatment claim.”These are claims that are sent to the insurance carrier before aprocedure is performed. For example, pretreatment claims are oftenrequired by dental insurance companies on any procedure over a specifiedamount, e.g., $200. The aspect of this type of claim which renders itincompatible with the present electronic claim processing system is thatthe insurance companies require that additional medical evidence beincluded, i.e., attached to, the text part of the claim form. In anexemplary case, the additional medical evidence is an x-ray.

[0015] The goal of the insurance company is to review the claim, i.e.,both the text form and attachment, and to do so in a cost effectivemanner. The natural next stage in the development of claims processingsystems is to attempt to computerized this process.

[0016] Scanners are now available that can digitize a dental x-ray,i.e., convert it into a computer file that can be viewed on a monitor.But transforming the medical evidence into digital form is not enough tofacilitate electronic processing of claims with attachments. One mustalso take into consideration the existing claims processinginfrastructure, i.e., the legacy infrastructure.

[0017] The difficulty with trying to include a digitized x-ray forprocessing with an electronic claim form, within the currentinfrastructure, is multifaceted. First, NEIC does not at the presenttime allow this type of information to be transmitted through NEIC tothe insurance companies. Second, with the current system, the claimsadjusters access claims information through terminals connected tomainframes. But there is the inherent problem of displaying images onmainframe computers. This is especially true of mainframe computersrunning software written in business programming languages such asCOBOL. It might be thought that a solution to this problem would be toreplace the terminal with a PC. Although many personal computers providethe graphics support needed to display the digitized x-ray, there aresignificant problems in interfacing a PC with a mainframe computer. Forexample, in order to interface with the mainframe computer, PCs oftenrun terminal emulation software which permits the PC to act like adedicated, dumb terminal attached to the mainframe computer. Terminalemulation software is notoriously lacking in graphics capability. Third,insurance company legacy computer systems were, in general, designed toaccept a specific electronic form. An attachment would represented newinformation that this form was not designed to handle. This could, forexample, be an additional field on the form or an image in one of thefields. Consequently, the legacy information system can't handle the newinformation without major modifications. Since the legacy system wasdesigned to handle a specific form, an “attachment” could be defined as“any additional information not included in this form.” And finally,getting a digitized x-ray from one provider to one insurance company isnot all that is needed. Rather, what is really needed is anindustry-wide system whereby a provider can interact with any insurancecompany. This results in a massive interfacing problem since there aremultitudes of insurance companies using different legacy hardwaresystems and company unique software. Technologically, this interfacingproblem is identical to that where many buyers are trying to interact(i.e., exchange transactions) with many sellers.

[0018] Each time a way has been found to more fully utilize computers inclaims processing systems, the administrative costs associated withclaims processing have gone down. However, in the area of “claims withattachments,” no coherent industry-wide, i.e., global, system existsthat allows for the integrated filing, transmitting and processing ofthese claims electronically, i.e., via computers. Thus, when attachmentsare required, providers are forced to submit hard copy claimapplications, while insurance companies labor under an administrativesystem that is a hybrid between a manual and an electronic system, i.e.,a hybrid between stage #1 and stage #2. This hybrid system, which isdescribed in greater detail below, is labor intensive, prone toproblems, and slow. For providers, insurance companies, and patients,this is a time-consuming, costly and irritating process.

[0019] In short, there is at least one type of insurance claim that hasnot, until now, been able to avail itself of the third stage ofcomputerization, as described above. In fact, there are evendifficulties with the second stage. This group includes any claim whose“standard text form” must be accompanied by additional information thatdoes not fit into this standard format, e.g., x-rays, EKGs, additionaltext information such as Operating Room Reports, etc. In general, theseare referred to as “attachments.” One primary example of this would bePrior Approvals for dental procedures. Prior Approval claim (PAC)applications are those claims that are submitted for the purpose ofreceiving a predetermination of benefits from the insurance company fora procedure that hasn't as yet been performed.

[0020] In the area of Prior Approval claims, the goals of the insurancecompanies are to validate the necessity of the procedure and todetermine whether the patient's insurance policy obligates the insurancecompany to pay for such a procedure, i.e., authorization andeligibility. This requires that the insurance company itself review themedical evidence. For an insurance company's in-house dentist, forexample, to make this appraisal, the dentist is required to review boththe “text form” and the accompanying x-ray of the patient. However, thepresence of a film x-ray means that electronic claims methods cannot beimplemented. The savings associated with electronic claim processing isnot available with respect to Prior Approval claim forms.

[0021] Nationwide, there are approximately 200,000 dental PACs filed perweek. Roughly, for every PAC application there will be eventually aFinal Payment claim (FPC) submitted when the medical procedure iscompleted. It is estimated that the overall administrative cost is $25per PAC form and to $10 for the Final Payment claim. It is alsoestimated that if a coherent electronic system could be implemented, itwould reduce these administrative costs to $15 per PAC and $5 per FinalPayment claim. The savings could amount to as much as $3,000,000 perweek collectively for the health care industry for dental PACs and FPCsalone.

[0022] An example of a hybrid system of claim processing currently inuse will now be described with reference to FIGS. 1, 2A and 2B.

[0023] Referring first to FIG. 1, the U.S. Postal Service, denoted as100, connects the service provider's office 200 with the insurancecompany 300. It will be appreciated that, since PAC form handling isentirely manual at location 200, the service provider's office isdepicted as lacking computer equipment. In contrast, the insurancecompany typically has at least one mainframe computer 350 to whichterminals 351, 352 on the respective reviewing dentist's and claimsadjuster's desks are connected. It should also be noted that the mailroom 320 is charged with a variety of tasks associated with the incomingand outgoing correspondence, as discussed in greater detail below.

[0024] As will be appreciated from FIG. 1, a paper PAC form is filledout by the patient and/or the provider and, along with thesubstantiating x-ray, is mailed to the patient's insurance company. Uponentering the mail room of the insurance company, the PAC form isassigned a document identification number (DIN) and the data from thePAC form is then entered into the company's mainframe computer. Thissame DIN is affixed to the x-ray. The x-ray is then manually deliveredto the reviewing dentist.

[0025] By using the DIN on the x-ray, the reviewing dentist downloads,from the mainframe computer, the textual part of the patient's PACapplication. The dentist makes a decision, records it in the memory ofthe mainframe computer, and has a hard copy of the Predetermination formposted back to the provider. Once the procedure has been completed, theprovider's office completes the Predetermination form, or fills out aseparate Final Payment claim (FPC) form. This is then posted to theinsurance company. A chronological, detailed, step-by-step descriptionof the hybrid system will now be provided with reference to FIGS. 1, 2Aand 2B.

[0026] During step S1, the dentist decides that a costly procedure isnecessary for a patient whose insurance carrier requires prior approvalfor such treatment. During step S2, the dentist provides the patientwith his diagnosis and gives the patient an estimate for performing therecommended procedure. The dentist then asks the patient to contact hisinsurance carrier, or plan administrator at work, to obtain thenecessary PAC form. During step S3, the patient completes that portionof the PAC form that pertains to him, signs the form, and sends it tohis provider.

[0027] After the PAC form arrives at the provider's office at step S4,one of the office personnel retrieves the patient's file and the PACform at step S5, extracts the patient's x-ray, either the original, acopy of the original, or a second, previously taken x-ray, during stepS6, and the PAC form is filled out entirely by hand, i.e., theinformation about the provider has to be entered every time a new PACform is received, during step S7. Copies of the completed form are madeand are placed in the patient's file during step S8. The envelopecontaining the PAC form is addressed to the appropriate insurancecompany at step S9. The form and the x-rays are placed in the envelopeduring step S110. An entry is made in both the patient's computer file(if the provider's office is equipped with one) and his hard copy fileindicating that the PAC form has been sent during step S11 and, finally,during step S12, the envelope is mailed. See task T1 in FIG. 1.

[0028] The envelope meanders through the U.S. Postal Service 100 forseveral days at step S13 until the envelope finally arrives at the mailroom 320 of the insurance company 300 at step S14. In the mail room, theenvelope is opened (step S15), the data from the PAC form is enteredinto the insurance company's mainframe computer 350 and is given aDocument Identification Number (DIN) that identifies the patient and thecurrent claim application (step S16). See task T2 in FIG. 1. During stepS17, the x-ray is labeled with the same DIN. It will be appreciated thatthe DIN on the x-ray and in the document now on the mainframe computermust be identical. It will also be appreciated that for some insurancecompanies, this manual processing is contracted to an outside agency,which would require several more steps, which steps will not bedescribed further.

[0029] During step S18, the x-ray is manually forwarded to the reviewingdentist's area. See task T3 in FIG. 1. During step S19, the PAC form istransferred to a directory and waits to be read by a reviewing dentist.

[0030] During step S20, a group of x-rays arrives from the mail room atthe reviewing dentist's area. A film x-ray is pulled out of the waitingpile by the dentist during step S21 and the reviewing dentist thenaccesses the “PAC form” directory during step S22 by, for example,reading the DIN from the x-ray and typing the DIN into the computer. Theelectronic PAC form corresponding to this x-ray is located in memory anddownloaded to the reviewing dentist's monitor during step S23.

[0031] The procedure requested is read off the terminal monitor and thefilm x-ray is reviewed during step S24 and a determination is madeduring step S25. It will be appreciated that a determination refers toeither an approval or a denial of the request. Assuming that theprocedure is approved, a statement (or explanation) of benefits (EOB) isalso generated. For the purposes of this discussion, it will be assumedthat the procedure is approved; a denial would necessitate a parallelbut alternative set of processing steps, which steps will not be furtherdescribed. During step S26, the insurance company's Predeterminationform is filled out either electronically or by hand. For an electronicPredetermination form, the form is saved to the memory of the insurancecompany's mainframe computer during step S27. The x-ray is returned tothe mail room during step S28. See task T4 in FIG. 1.

[0032] Following approval, a paper copy of the Predetermination form ismade during step S29. See task T5 in FIG. 1. An envelope is thenaddressed to the referring dentist and the Predetermination form isplaced in the envelope during step S30. During step S31, thecorresponding x-ray is matched with the Predetermination form and,during step S32, the corresponding x-rays are placed in the envelope.The envelope then goes back into the U.S. Postal System 100 during stepS33. See task T6 in FIG. 1.

[0033] Some days later, the envelope finally arrives at the dentist'soffice 200 and is opened during step S34. The results are noted in boththe patient's paper file and computer file (if the dentist maintainsone) during step S35, the x-rays are returned to the patient's paperfile at step S36, and the patient is notified of the approval and a dateis set for performing the approved treatment during step S37.

[0034] The treatment is completed during step S38 and the Final Paymentclaim (FPC) form is filled out during step S39. It will be appreciatedthat the Final Payment claim form, for many insurance companies, ismerely a subsection of the Predetermination form generated in step S29(See the paper denoted P* in FIG. 1.); alternatively, the Final Paymentclaim form could be yet another form supplied by the insurance company.

[0035] The Final Payment claim form is then sent back to the insurancecompany with a copy of the signed Predetermination form during step S40.See task T7 in FIG. 1. The Final Payment claim form enters the mail roomas a paper form and the final processing begins during step S41. It willbe appreciated that the processing of the Final claim Form typicallyrequires making several entries in the information stored on themainframe computer 350 and may require the preparation of one or moreforms needed to authorize payment of the final claim. However, since anattachment is not normally associated with the Final claim Form,additional discussion regarding disposition of the Final claim Formwithin the insurance company will not be provided.

[0036] Thus, the hybrid system under discussion is one that starts inthe provider's office when a patient is told that a PAC form is neededand continues until the procedure has been completed and a Final Paymentclaim form has been submitted to the insurance company for payment. Itwill be appreciated that a myriad of problems and inefficiencies arisedue to claim processing in accordance with the hybrid system. Theprincipal problems are as follows:

[0037] 1. All information needed to complete the PAC form has to beentered by hand. Moreover, all of the information on the PAC form isalso manually transcribed in order to transfer the information frompaper to the insurance company's mainframe computer. Both of thesemanual data entry process steps are time consuming, very costly, andprone to human error;

[0038] 2. The x-ray film and the text form are put together and thenseparated several times during the overall claim processing;

[0039] 3. The hybrid system requires that a hard copy of the x-ray besent to the insurance company. Generally, this x-ray is returned to theprovider. Moreover, the requirement that the dentist provide the x-raytypically means that a duplicate x-ray has to be made by the dentist,which increases the dentist's cost for the service. Oftentimes, theduplicate x-ray is of poor quality and cannot be read;

[0040] 4. Because prior approval claim forms cannot be processedelectronically, and because PAC forms make up half of all the claimsthat approximately 20,000 oral surgeons, periodontists, andorthodontists make each year, these 20,000 providers have no compellingreason to initiate electronic claims for Final Payment claims;

[0041] 5. The document identification number is affixed to the x-ray andthe electronic text in two different processes, one physical and theother electronic. This leads to errors;

[0042] 6. After the procedure has been completed, almost identicalinformation may again have to be entered by hand in order to prepare theFinal Payment claim form;

[0043] 7. While direct digital x-ray equipment is available, it isdifficult to integrate a digital x-ray into the current hybrid claimsprocessing system, i.e., these computerized images would first have tobe transferred to film, which would, of course, negate the majoradvantage for using direct digital x-rays;

[0044] 8. Some insurance companies would like to require that x-raysaccompany all dental claims; they are prevented from doing so because ofthe high administrative overhead associated with handling hardcopyclaims;

[0045] 9. The patient has to obtain the PAC form from the insurancecompany or his employer. In either case, this causes the patient time,is an irritant, and imposes unnecessary delays on the delivery ofmedical care to the insured;

[0046] 10. With the hybrid system, no prescreening of the PAC form forerrors is performed before the PAC form goes to the insurance company;and

[0047] 11. Provider information, i.e., the dentist's information, oftenhas to be entered separately on each new PAC form that is submitted.

[0048] In summary, the current method for handling PAC applications is ahybrid system somewhere between a Stage 1, a totally paper-based manualprocessing system, and a Stage 2 internally computerized insurancecompany processing system. It is part electronic and part hard copy.Also, each form must be handled twice, once as a hard copy and once asan electronic copy. This is the source of a great many of the abovedescribed problems. Moreover, the current hybrid method is costly. Theprocess starting at the provider's office, continuing through theinsurance company and finally to the return of the Predetermination formto the provider has been estimated to cost $25. Furthermore, the wholeprocess is filled with potential for error, frustration, wasted time andmoney.

[0049] The workflow for the filing and processing of a PAC form wasdescribed above with respect to the dental health insurance which wasused, by way of example, to illustrate the circuitous process involvedwhen a hard copy attachment is present. Other types of claims, orattachments, or different insurance companies might require slightlydifferent steps. For example, instead of returning an attachment, asdescribe above, the attachment might need to be microfilmed andarchived, or some of the information contained in the attachment itselfmight need to be entered into the mainframe. Regardless of thesedifferences, there are similarities in the problems that arise inprocessing such claims.

[0050] The present invention was motivated by the desire to overcome theproblems associated with the above-described hybrid system forprocessing “forms with attachments.” The intent was to create a coherentsystem that allows for the electronic filing, transmission, andprocessing of these forms, e.g., claims. That is, a system that wouldcreate a Stage #3 level of computerization for “forms with attachments.”More specifically, the present invention was motivated by the desire toeliminate, to the maximum extent possible, all processing stepsdescribed above which are in any way connected with the presence of ahard copy attachment.

SUMMARY OF THE INVENTION

[0051] One purpose of the present invention is to create a coherentsystem that allows for the electronic filing, transmission, andprocessing of “insurance claims with attachments,” and to therebyovercome the many deficiencies of the hybrid system claims processingmethodology described above.

[0052] Thus, one object according to the present invention is to providea PAC form processing system which minimizes the necessity of manualdata entry. According to one aspect of the present invention, only about40% of the information needed to complete the PAC form has to be enteredby hand. According to another aspect of the present invention, theamount of information that has to be manually re-entered by an operatoris essentially zero.

[0053] Another object according to the present invention is to provide aPAC application processing system which eliminates handling errorsresulting in a mismatch between, for example, a PAC form and anassociated patient x-ray. According to another aspect of the invention,mismatch errors are virtually eliminated since the electronic x-ray andthe associated text are never separated; field data included in, forexample, the PAC form is copied and transferred between the server andthe mainframe computer systems inside the insurance company. Accordingto yet another aspect of the invention, mismatch errors are virtuallyeliminated since no hard copy of the x-ray is ever sent to the insurancecarrier.

[0054] Still another object according to the present invention is toprovide a PAC application processing system which increases the numberof service providers employing electronic claims systems to therebyreduce the overall claims processing costs. Since a PAC form can now behandled electronically in accordance with the present invention,electronic final payment claims become viable for approximately 20,000additional dentists.

[0055] A still further object according to the present invention is toprovide a PAC application processing system in which DocumentIdentification Numbers, or some other method of uniquely specifying thePAC, are simultaneously associated with both the text and the x-ray by asingle computer entry.

[0056] Yet another object according to the present invention is toprovide a PAC application processing system which operates at lowercost. Cost efficiencies are readily achieved according to the presentinvention by eliminating the need to send a physical x-ray with theclaim.

[0057] Another object according to the present invention is to provide acost effective claim processing system wherein little or no informationon either the PAC form or the Predetermination form has to be manuallyre-entered.

[0058] Still another object according to the present invention is toprovide a system for packaging textual data with an associated digitizedx-ray for transmission to an insurance company. It will be appreciatedthat direct digital images are easy to integrate into the system becausesuch images are already in the form of a computer file.

[0059] Another object according to the present invention is to provide atotally digital PAC application processing system which can accommodateboth text and digitized x-rays at low cost, thereby allowing insurancecompanies to require x-rays with all claims because such requirementswill not significantly increase the processing cost associated withnon-x-ray documented claims.

[0060] An additional object according to the present invention is toprovide a totally digital PAC application processing system in which acustomizable claim form, i.e., the PAC form, which addresses the needsof all insurance carriers is stored in the memory of the computer inevery service provider's office. This, in combination with anon-clearinghouse communications channel and having AIC system softwareat all of the insurance carriers, then eliminates the need for imposingindustry-wide standards, such as ANSI ASC X12, for claim-relatedelectronic transactions. The present invention allows each individualinsurance company to get the information that it requires and to getthat information in what ever format that insurance company prefers.Moreover, the ability to transmit the customizable claim form andintegrated attachment to an insurance carrier via a non-clearing housecommunications channel advantageously permits the transmission of othertypes of claims, including worker's compensation claims, to theinsurance carrier. In addition, it will eliminate the irritant of thepatient or provider having to obtain a PAC form from a particularinsurance company.

[0061] Another object according to the present invention is to provide atotally digital PAC application processing system in which prescreeningof information entered into a PAC form, which is stored in the memory ofthe computer in the service provider's office, is easily performed.

[0062] Yet another object according to the present invention is toprovide a totally digital PAC application processing system in whichprovider information is automatically entered into each PAC form.

[0063] It will be appreciated that none of the above-identified objectsneed actually be present in the invention defined by the appendedclaims. In other words, only certain, and not all, objects of theinvention have been specifically described above. Numerous other objectsadvantageously may be provided by the invention, as defined in theappended claims, without departing from the spirit and scope of theinvention.

[0064] According to one aspect, the present invention provides acombination of storage media storing computer readable instructions forpermitting non-networked computers to cooperate synergistically,including first, second, and third storage media. Preferably, the firststorage medium stores computer readable instructions for permitting afirst computer system to receive textual data as field data, to assemblethe field data and a corresponding digitized attachment into a firstfile and to transmit the first file to a second computer system via theInternet, while the second storage medium stores computer readableinstructions for permitting the second computer system to receive thefirst file via the Internet, to display the first file including thedigitized attachment on a first window generated by a graphics userinterface (GUI) instantiated by the second computer system, to display asecond file in a second window, and to transfer the field data to athird computer system operatively connected to the second computersystem. Additionally, the third storage medium stores computer readableinstructions for permitting the third computer system to receive thefield data from the second computer system, to process the field data tothereby generate the second file including portions of the field dataextracted from the first file, and to transmit the second file to thesecond computer system.

[0065] According to another aspect, the present invention provides acombination of storage media storing computer readable instructions forpermitting non-networked computers to cooperate synergistically,including first, second and third storage media. More specifically, thefirst storage medium stores computer readable instructions forpermitting a first computer system to receive textual data as fielddata, to assemble the field data and a corresponding digitizedattachment into a first file and to transmit the first file to a secondcomputer system via the Internet, the second storage medium storescomputer readable instructions for permitting the second computer systemto receive the first file via the Internet, to display the correspondingfirst field data in a first window generated by a graphics userinterface (GUI) instantiated by the second computer system, to displaythe digitized attachment in a second window, to display a second file ina third window, and to transfer the field data to a third computersystem operatively connected to the second computer system, and thethird storage medium stores computer readable instructions forpermitting the third computer system to receive the field data from thesecond computer system, to process the field data to thereby generatethe second file including portions of the field data extracted from thefirst file, and to transmit the second file to the second computersystem.

[0066] According to yet another aspect, the present inventionencompasses a system for transmitting and receiving attachmentintegrated files, each containing a plurality of field data anddigitized data corresponding to at least one of the field data, over theInternet, the system including a first computer system and a secondcomputer system. The first computer system advantageously includes afirst memory storing a first software module containing first operatinginstructions readable by the first computer system, a first displaydevice for displaying a predetermined first form, the first form beingstored in the first memory, a first input device permitting entry offirst alpha-numeric characters into the first form, and a firstprocessor for converting the first alpha-numeric characters into fieldsto thereby generate first field data, and converting the first fielddata and the digitized data into one of the attachment integrated filesresponsive to the first operating instructions. Preferably, the secondcomputer system, which receives the one of the attachment integratedfiles from the first computer system via the Internet, includes a secondmemory storing a second software module containing second operatinginstructions readable by the second computer system, a second inputdevice permitting entry of second alpha-numeric characters required tocomplete a second form into the second form, a second display device fordisplaying the first form, the second form, the first and second formsbeing stored in the second memory, and the digitized data, wherein atleast a portion of the first alpha-numeric characters are exhibited inthe first and second forms simultaneously, and a second processor forautomatically inserting the second alpha-numeric characters into fieldsto thereby generate second field data, and automatically generating anoutgoing message containing the second field data responsive to thesecond operating instructions.

[0067] According to a still further aspect, the present inventionprovides a system for transmitting and receiving attachment integratedmail messages, each containing a plurality of field data and digitizeddata corresponding to at least one of the field data, over the Internet.Advantageously, the system includes:

[0068] a first device generating one of the attachment integrated filesincluding:

[0069] a second device storing first operating instructions readable bythe first device;

[0070] a third device generating the digitized data;

[0071] a fourth device exhibiting a predetermined first form, the firstform being stored in the second device;

[0072] a fifth device entering first alpha-numeric characters into thefirst form; and

[0073] a sixth device converting the first alpha-numeric characters intofields to thereby generate first field data, and converting the firstfield data and the digitized data into the one of the attachmentintegrated files;

[0074] a seventh device which transmits the one of the attachmentintegrated files over the Internet; and

[0075] an eighth device receiving the one of the attachment integratedfiles from the seventh device, including:

[0076] a ninth device storing second operating instructions readable bythe eighth device;

[0077] a tenth device for entering second alpha-numeric charactersrequired to complete a predetermined second form into the second form;

[0078] an eleventh device for exhibiting the first form, the secondform, the first and second forms being stored in the ninth means, andthe digitized data, wherein at least a portion of the firstalpha-numeric characters are exhibited in the first and second formssimultaneously; and

[0079] a twelfth device for converting the second alpha-numericcharacters into fields to thereby generate second field data, and forgenerating an outgoing file containing the second field data.

[0080] According to a still further aspect, the present inventionprovides a method for permitting non-networked computers includingfirst, second and third computers, each of the first, second and thirdcomputers including a memory, an input device, and a display,respectively, the first and the second computers being connected to oneanother by the Internet, and the first computer including a digitizingdevice, to cooperate synergistically. Preferably, the method includessteps for:

[0081] (a) retrieving a first form from storage in the first computer'smemory and displaying the first form on the first computer's display;

[0082] (b) writing first field data to the first form using the firstcomputer's input device;

[0083] (c) generating a digitized attachment;

[0084] (d) combining the digitized attachment and the first form so asto generate an attachment integrated file;

[0085] (e) transmitting the attachment integrated file to the secondcomputer via the Internet;

[0086] (f) transmitting the first field data from the second computer tothe third computer;

[0087] (g) generating a second form upon receipt of the attachmentintegrated file, the first and second forms containing at least aportion of the first field data on the third computer;

[0088] (h) displaying the first form, the second form and an imagecorresponding to the digitized attachment in respective windows of agraphical user interface (GUI) generated by the second computer;

[0089] (i) inserting second field data into the second form using thesecond computer's input device;

[0090] (j) transmitting the first and second field data corresponding tosecond form back to the first computer via the Internet.

[0091] According to another aspect, the present invention encompasses amethod for operating a computer network including first and secondcomputer systems connected via the Internet, each of the first andsecond computers including a memory, an input device, and a display,respectively. The method includes steps for:

[0092] (a) retrieving a first form from storage in the first computersystem's memory and displaying the first form on the first computersystem's display;

[0093] (b) writing first field data to the first form using the firstcomputer system's input device;

[0094] (c) combining a digital attachment and the first form so as togenerate an attachment integrated file;

[0095] (d) transmitting the attachment integrated file to the secondcomputer system over the Internet;

[0096] (e) generating a second form upon receipt of the attachmentintegrated file, the first and second forms containing at least aportion of the first field data;

[0097] (f) displaying the second form and an image corresponding to thedigital attachment on a graphical user interface (GUI) instantiated onthe second computer system's display; and

[0098] (g) writing second field data to the second form using the secondcomputer system's input device.

[0099] These and other objects, features and advantages of the inventionare disclosed in or will be apparent from the following description ofpreferred embodiments.

BRIEF DESCRIPTION OF THE DRAWINGS

[0100] The preferred embodiments are described with reference to thedrawings in which like elements are denoted by like or similar numbersand in which:

[0101]FIG. 1 is a combination high level block diagram and flow diagramwhich is useful in understanding the operation and attendant problems ofthe current hybrid system for Prior Approval claim form processing;

[0102]FIGS. 2A and 2B collectively form a flow chart which illustratesin greater detail the steps needed to implement the hybrid system ofFIG. 1;

[0103]FIG. 3 is a combination high level block diagram and flow diagramwhich is useful in understanding the operation and system of PriorApproval claim form processing according to a preferred embodiment ofthe present invention;

[0104]FIG. 4 is a detailed flow chart of the operational steps needed tooperate the system illustrated in FIG. 3;

[0105]FIGS. 5A and 5B illustrate alternative embodiments of theattachment integrated claim application according to two of thepreferred embodiments of the present invention; and

[0106]FIGS. 6A and 6B illustrate clearinghouse and non-clearinghousenetworks, respectively, connecting service providers and insurancecompanies.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0107] The present invention is a system and corresponding methodimplemented by software loaded onto the system for processing textualmessages which are integrated with one or more attachments. Heretofore,such attachments could not be readily and/or usefully incorporated withthe textual message. Hereinafter, the term Attachment Integrated claim(AIC) Application will be used to denote a claim application including atext portion and a digital attachment portion. An exemplary embodimentof the present invention combines a patient's digitized x-rays with anelectronic insurance claim form to create an electronic Prior Approvalclaim (PAC) Application. Another preferred embodiment of the presentinvention is an industry-wide system for the electronic filing andprocessing of these PAC Applications.

[0108] It should be noted that the term “digital attachment” as usedhereinafter is not limited to a digitized image or x-ray. The term“digital attachment” is understood to embrace x-rays, CTs, MRIs, EKG orEEG recordings, i.e., strip charts, digitized video signals such asMoving Picture Experts Group (MPEG) compressed video signals,transcriptions of Operating Room Notes, estimates for repairs to a houseor car, Explanation of Benefits (EOBs), additional ASCII text, and thelike. Moreover, all particulars regarding a specific “attachment,” suchas medical specialty, acquiring modality, the patient's problem, etc.,are to be ignored, since such details have absolutely no bearing on thevarious embodiments of the present invention. The only requirementsregarding digital attachments are that the information must be somethingthat can be digitized, i.e., put into the form of a computer file, andthat once in this form, it can be “read, reviewed or interpreted” by theperson or organization receiving it.

[0109] The preferred embodiments according to the present invention willnow be described with reference to FIGS. 3 and 4. In particular, asshown in FIG. 3, the overall system according to the present inventionincludes the computer components 200 located in the health careprovider's office and the computer components 300 located on thepremises of the insurance company. Included, in the exemplary embodimentof the present invention, are the computers 210 at the provider's officeand 350 at the payer's office. These can be, for example, legacycomputer components of a Stage III claims processing system. Added tothese, in the exemplary embodiment, are the AIC server 316 and theconnection between the AIC server and the legacy mainframe. These newhardware items, along with new AIC software modules (to be describedbelow) when added to the legacy computers items 210 and 350 form a newand more dynamic computer system. Finally, infrastructure 400, whichadvantageously may be an existing on-line service company, is preferablyused in the exemplary embodiment of the present invention to facilitatecommunication between the components 200 in the service provider'soffice and the components 300 at the insurance company. Preferably,components 500, which are located at a value-added service company,permit services ordered by the service provider, patient, or insurancecompany to be performed. It should be noted that the components 500 mayduplicate a subset of the components 300 found at the insurance companyand, for that reason, description of the components 300 alone will beprovided below.

[0110] It should also be mentioned that the description which followsdescribes the invention as it is used in connection with dentalinsurance forms. However, the present invention is not limited tosystems for the processing of dental insurance claims. Rather, thepresent invention encompasses the preparation, transmission andprocessing of data packages including a plurality of data fields whereinat least one of the data fields is a digital attachment, e.g., a digitalimage. For example, casualty insurance claims with supportingdocumentation, i.e., pictures taken with a digital camera, are withinthe scope of the present invention.

[0111] As shown in FIG. 3, the components 200 include a personalcomputer 210 including a screen 212, a keyboard 214 and a modem 216,connected to a scanner 220, a printer 230 and an archiving device 240,e.g., a large memory for storage of digital information. Device 240advantageously may be a writeable compact disc read only memory(CD-ROM), i.e., a so-called write once—read many (WORM) device, a harddisk drive, a tape back up device or a removable hard disk device. Itshould be recognized that the computer 210 advantageously can be acomputer system including a central processing unit, a graphic displayprocessor, the graphic display device 212, and several memoriesincluding both solid state memories and a hard disk drive. It shouldalso be noted that the archive device 240 and one of the memoriesassociated with computer 210 may be the same memory device.

[0112] Components 300 located at the insurance company include thepreviously described mainframe or legacy computer 350 and associatedterminals 351, 352. In addition, a buffer computer 310, which may be anetwork server (i.e., a network server is but one example; Component 310could be any digital device, or combination of digital devices, whichproduce the required results as described in detail and summarizedbelow.), includes a modem 316 and is connected to a printer 330 and astorage device 340. The printer 320 may provide copies of documentsdirectly to the mailroom 320. Preferably, the computer 310 is connectedto personal computers or work station terminals 311, 312 via a localarea network (LAN) 313. The buffer computer 310 and the mainframecomputer 350 are electronically connected to one another. The details ofsuch a connection are well known to one of ordinary skill in the art andwill not be described in greater detail.

[0113] Before presenting a detailed description of preferred embodimentsaccording to the present invention, a brief overview of the operatingmethod steps associated with formation, transmission and processing ofthe PAC Application will now be presented. In an exemplary andnon-limiting case, the essential steps of the operating method include afirst subroutine for completing and transmitting needed information to adesignated insurance company. This subroutine includes steps for:

[0114] (1) Retrieving an appropriate electronic PAC form from storage inthe computer's memory and displaying the PAC form on the computerscreen;

[0115] (2) Filling out of PAC form on the computer screen;

[0116] (3) Digitizing, e.g., scanning, the patient's x-ray;

[0117] (4) Combining the digitized x-ray and the electronic PAC forminto the patient's PAC application; and

[0118] (5) Transmitting the patient's PAC application to the designatedinsurance company.

[0119] After the PAC application is received by the insurance company,the insurance company performs another subroutine, which includes stepsfor:

[0120] (6) Reviewing the PAC application;

[0121] (7) Generating an electronic Predetermination form when theapplication has been reviewed; and

[0122] (8) Transmitting the electronic Predetermination form back to theinsured's Service Provider.

[0123] When the electronic Predetermination form from the insurancecompany is received by the service provider, an additional subroutine isperformed by the service provider. This subroutine advantageouslyincludes steps for:

[0124] (9) Reading the electronic Predetermination form;

[0125] (10) When the approved procedure has been performed, addingcompletion data to the electronic Predetermination form; and

[0126] (11) Transmitting the annotated electronic Predetermination formback to the Insurance Company.

[0127] When the annotated electronic Predetermination form is receivedfrom the service provider, the insurance company performs a finalsubroutine, which includes steps for:

[0128] (12) Reviewing the annotated information; and

[0129] (13) Issuing the final payment to the service provider.

[0130] The method for operating the system according to a preferredembodiment of the present invention will now be described in detail.

[0131] The method starts at step S101 with the service provider'sdiagnosis that a costly procedure is necessary. It is then determinedthat the patient needs prior approval from his insurance company. Duringstep S102, the patient is provided with an explanation of the procedureand a cost estimate for that procedure. The service provider and thepatient then prepare the needed PAC Application.

[0132] During step S103, a member of the service provider's office staffaccesses the Attachment Integrated claims (AIC) software stored innon-volatile memory on the service provider's computer system 210, whichsoftware advantageously is Graphic User Interface (GUI) software.Preferably, this AIC software is written in C++, Visual Basic, or someother appropriate graphical programming language.

[0133] It will be appreciated that commercial software packages, such asLOTUS NOTES™, have been designed with the capability of addressingcombinations of text and graphics files. However, the purpose of thesepackages is to create an “environment” or “platform” in which specificapplications can be developed. In contrast, the preferred embodimentsaccording to the present invention are directed at providing integratedtext and graphics files within a coherent system and methodology foraddressing the specific needs of the work flow, preferably of aparticular industry. That is, it is a particular application. It ispossible, but not necessary, that the software needed to implement thepreferred embodiments of the present invention can be developed withinthe frame work of the environment created by something such as LOTUSNOTES™. Alternatively, the software needed to implement the preferredembodiments of the present invention can be developed using JAVA™applets.

[0134] Contained within the AIC software are PAC forms for insurancecompanies using the AIC system. When one of these is opened it acts as atemplate upon which a new computer file will be based. This computerfile will ultimately contain the patient's PAC Application.

[0135] It will be appreciated that the PAC form when displayed on thecomputer's screen 212 contains boxes, such as those depicted in FIGS. 5Aand 5B, in which alpha-numeric characters can be entered so that, whenthe characters are entered in these boxes they are entered so as to filla “field,” a delimited alpha-numeric character string. Being a “field,”the information denoted by the characters can be transferred to and usedin completing other fields in related documents. Also, the informationitself, or lack thereof, can be used as a logic control device, e.g.,used to remind the preparer that critical information has not beenentered. In summary, all the information of the “PAC Application” fileis in the form of fields, and each field is identified, by some means,as to its content.

[0136] In the exemplary case being discussed, the PAC forms of manyinsurance companies have been encoded and stored in memory on theservice provider's computer system 210. This can be advantageously donein the following way. The PAC forms for all the insurance companiesusing the AIC System are gathered. Then a union of all the informationrequested in these PAC forms is made. A field is created for eachelement of information requested. For example, Field #1 contains thepatient's first name, Field #2 contains the patient's last name, and soon. This is done until the “information fields” of the PAC forms for allof the insurance companies are included.

[0137] In order to increase the efficiency of the clerical staff at theprovider's office, it is desirable to give them basically the same formto fill out every time, i.e., a Standard User Interface (SUI) whereinformation is always in the same place on the form. To do this atemplate is created. What actually appears on the screen of the prepareris always the same. What changes is that any given insurance companywill desire only a particular subset of the total number of fields. Soif insurance company A is chosen, then fields 1,2,3,7,9, . . . have tobe filled in, whereas, if insurance company B is chosen, then fields2,3,4,5,7,11, . . . have to be filled in. The fields not needed areautomatically signified in some way by the AIC software, e.g., ifinsurance company A does not need Field #4 then that block on the screenis gray and can't be typed into (i.e., is “write protected”). Thus a“customized claim form” is provided for every insurance company based ona single, universal compilation of fields. As described below, whatallows this method to work is that there is AIC software at theinsurance company that has been coordinated with the AIC software at theproviders office.

[0138] The AIC Software GUI asks for the name of the insurance company,which can be typed in or selected from a directory. Once the insurancecompany has been identified, the fields needed to complete the insurancecompany's PAC form are displayed on the screen 212 of the serviceprovider's computer system 210. The AIC software advantageously canautomatically fill in all the parts of the form that are specific to theservice provider, e.g., name, address, Provider Identification Number(PIN), etc. It is estimated that this alone eliminates 20% of the workneeded to fill out the PAC form. An electronic signature couldadvantageously be added at this time for the service provider or couldbe added as part of the final review and approval before the completedPAC application is transmitted.

[0139] Needed patient information is then entered into the PAC form onthe computer screen 212, preferably while the patient is still in theoffice, and a provider Document Identification Number (PDIN) can be usedto label the form, if so desired. This is now a computer file identifiedas referring to the patient. It should be noted that some form ofsignature can be provided in the appropriate field. As an example, aspecial electronic pad and pen can be used such that when the patientsigns on the pad his signature is affixed to the electronic PAC form.

[0140] During step S104, the patient's x-ray is digitized. In anexemplary case, there is a scanner 220, i.e., digitizer, connected tothe service provider's computer system running the AIC software. Thepatient's x-ray is scanned and converted into a series of orderednumbers (i.e., a bit map of the x-ray image) and stored. It should benoted that these stored series of numbers can be reconstructed by thecomputer system to display the x-ray on a computer monitor, i.e., thebit map can be used to reconstruct a raster image of the x-ray fordisplay.

[0141] It will be appreciated that the AIC software advantageously canbe written to minimize the time needed to scan the x-ray. In anexemplary case, the operator can specify the type of x-ray or x-raysthat are being scanned. This is done so that blank areas are not beingdigitized and added to the patient's file. It will be noted that thiswill also save on transmission time to the insurance company. Further,as will be readily appreciated by those skilled in the art, the text andimage data comprising the file can be encoded and compressed in anymanner well known in the art in order to minimize data storage andtransmitting claimed requirements.

[0142] It should also be mentioned that steps S1103 and S1104 need notbe performed in any particular order. In an exemplary case, thepatient's x-ray may be digitized before the PAC form is called up on thecomputer screen 212 and completed.

[0143] During step S105, the PAC application is formed from theelectronic PAC form and the digitized patient's x-ray. It should benoted that the present invention is not limited to a particular formatfor the PAC application. For example, the format of the PAC applicationadvantageously may consist of a text file and an associated digitizedimage file. It should be noted that in this case the text and imagefiles will be transmitted seriatim. For that reason, the text file(i.e., the PAC form) and the image file (i.e., the digitized x-ray) mustcross reference one another (i.e., be correlated) so that these filescan be continuously associated with one another after transmission tothe insurance company. If the attachment is simply additional ASCIItext, e.g., Operating Room Notes, then the only step necessary is totransfer the additional ASCII text into the integrated file format. Oncein the integrated file format, all processing is the same as if the filecontained an image attachment.

[0144] In an alternative exemplary case, the PAC applicationadvantageously can be prepared according to the Graphic InterchangeFormat© (GIF) specification, which specification is the intellectualproperty of CompuServe Incorporated. In order to form the PACapplication, the digitized x-ray is converted to a GIF image file. Itwill be appreciated that the GIF image file advantageously can includeone or more blocks of textual data denoted by a comment extension, asdescribed in Version 89a of the GRAPHICS INTERCHANGE FORMATdocumentation published by CompuServe, Inc. It should be noted thatsince the textual information corresponding to the data needed tocomplete the PAC form is included in the GIF image file comments, thepossibility of file separation and consequent mishandling or mismatchingof the separate components of the PAC application is virtuallyeliminated. Alternatively, the TIFF standard format advantageously canalso be used to co-join field and digital image data.

[0145] It will also be appreciated that the concept of embeddingcomments into the GIF or TIFF image file format is a standard practiceemployed by those of ordinary skill in the art of graphic imagepreparation, e.g., by photographers and digital artists who wish toidentify their works. However, it should also be noted that the use of acomment block storing data fields used in reconstructing a completedform, e.g., a completed PAC form, has never before been described orsuggested. Furthermore, since the technique described above is a novelsolution to electronically forwarding an insurance claim form and anassociated attachment as one, the use of the comment block to store thePAC form field data is likewise a unique and novel aspect according tothe present invention.

[0146] In yet another alternative exemplary case, the digitized x-ray isautomatically added (inserted) to the electronic form by the serviceprovider's AIC software and forms a single computer file, as depicted inFIG. 5A. It should be noted that the non-text portion of the PACapplication is labeled with the same provider Document IdentificationNumber (DIN) as used on the text portion, i.e., the electronic PAC form.These two objects together now form the patient record, i.e., thepatient's PAC application. The PAC application is now ready to be sentto the insurance company.

[0147] During step S106, the service provider's office staff thentransmits the completed PAC application to the insurance company. Forexample, when the transmission icon of the GUI AIC software running onthe service provider's computer system 210 is activated (e.g., “clicked”on), the following subsets are automatically executed:

[0148] (a) A check is first performed to ensure that the PAC applicationhas been completely filled out. In the event that problems and/or errorsare noted by the AIC software, the system user is notified of the errorby an appropriate annunciator, e.g., the suspect area can be highlightedand a message concerning the problem and/or error could be generated anddisplayed on the monitor;

[0149] (b) A hard copy of the PAC application is printed out, ifdesired, by the service provider. The hard copy may advantageously beplaced in the patient's permanent file;

[0150] (c) Moreover, and more importantly, the completed PAC applicationis archived in the service provider's computer system 210, 240. It willbe appreciated that this archive copy can be accessed in several wayssuch as by patient name, social security number, document identificationnumber, etc. That is, it can be accessed using any of the informationthat has been entered into the PAC form; and

[0151] (d) The service provider's computer system establishes aconnection with the on-line service 400 and transmits the patient's PACapplication to the insurance companies e-mail address. See task T1 a ofFIG. 3. It will be appreciated that the e-mail addresses of all theinsurance companies have been stored in the AIC software residing in thememory of computer system 210. Advantageously, the PAC application canbe transmitted immediately or can be scheduled for transmission at aconvenient time, i.e., can be transmitted after all of the PACapplications and other forms have been prepared for the day. Preferably,the AIC software on the service provider's computer system 210 keeps arecord of when the PAC application was sent. In addition, the AICsoftware maintains and uses the proper protocols so that when the PACapplication reaches the intended insurance company, it arrives therewith the alpha-numeric portion of computer file intact, i.e., theinformation is stored in fields that can be read by the correspondingAIC software module in the computer system 310 at the insurance company.

[0152] It should be noted that the specific transmission path taken bythe PAC application from the service provider's computer system 210 tothe computer system 310 maintained by the insurance company is not anessential limitation of the novel system and corresponding operatingmethod according to a preferred embodiment of the present invention. Theonly requirement of a transmission path is that it maintain the digitalintegrity of the PAC application computer file. Thus, the patient's PACapplication can be sent to the insurance company in several ways usingmodems 216 and 316, including via normal phone service, an on-lineservice, or bulk data transmission lines.

[0153] In an alternative exemplary case, the completed PAC applicationsmay even be transferred to tape or CD-ROM and then sent through the U.S.Postal Service 100 of FIG. 1 to the insurance company's mailroom 320.For purposes of the discussion which follows, only the exemplary case inwhich the PAC application is transmitted via the on-line service 400 isdescribed in any detail.

[0154] One of the beneficial aspects of the present invention isprovided by the combination of the customizable claim form on theservice provider's computer 210 and the use of any non-restrictivecommunications channel, i.e., the insurance companies are able to freelymodify information requirements demanded of the service providers.Existing electronic claims processing systems, such as NEIC, are basedon a clearinghouse concept, as illustrated in FIG. 6A. In a clearinghouse system, all claims enter the clearinghouse computer(s), aremanipulated, and then are transmitted to the appropriate insurancecompany. One consequence of the clearinghouse architecture is that itputs a constraint on the insurance company to use a standardized claimform. The individual insurance companies have little or no control ofthe information content in the form. Moreover, because the claim form isstandardized, changes are very difficult to make, i.e., any changerequires that all member insurance companies make the change together.

[0155] In contrast, placing AIC software packages in the providers'offices and in the insurance company processing centers, where thepackages are coordinated with one another, allows every payer totransmit claim form updates to every provider. There is no centralcomputer that manipulates the claim forms. In the provider's office, thechange would be reflected primarily in changes to the number of fieldsneeding information and, rarely, in the addition of a new field to becompleted by the provider.

[0156] As illustrated in FIG. 6B, the interchange between the provider'soffice and the insurance company(ies) advantageously can be performedusing an online service or Internet Service Provider (ISP), providingthat the service provider permits 8-bit file interchanges. In that case,the update information could be transmitted to the provider when theprovider dials into the online service. Thus, while it is true thattransmission accomplished using e-mail involves an intermediarycomputer, the online service merely provides a mail box and places noconditions on the insurance information contained in the claim itself.

[0157] Advantageously, the non-clearinghouse architecture andcoordinated AIC software package facilitates the provision of thecustomizable claim form. That is, each insurance company can determinethe content of its own claim form. The packages used by the providersare instructed regarding the information content, protocols, etc. eachinsurance company wants its claim to have. It will be appreciated thatthe package at each insurance company is designed to accept only thoseclaims that meet the specifications of the respective insurance company.In addition, if an insurance company wants to change the content of itsclaim form, it can do so independently of the other insurance companies.

[0158] Beneficially, the non-clearinghouse architecture reduces costs,allows for the direct digital interchange of data from one insurancecompany to another, and permits many different types of forms to be runoff the same system, e.g. commercial insurance claims and workers'compensation claims can both be processed in the provider's office usingthe same customizable claim form. This produces a claims processingsystem which is more robust than anything on the market today.

[0159] During step S107, the PAC application is pre-processed by thevalue-added service provider 500. For example, the patient's PACapplication can be accessed by the employees of the value-added servicecompany to perform services for either the patient, the serviceprovider, or the insurance company, or any combination thereof. See taskT2 of FIG. 3. These value-added services could include archiving of thepatient's dental x-rays so that all records for a particular patient arecentrally stored, screening of the entire PAC application for errors,compiling statistics on all PAC applications and, in some instances,even performing the review process for the insurance company.

[0160] Next, the insurance company accesses the PAC applications at theon-line service during step S108. In an exemplary case, each insurancecompany has an E-mail address specifically for the purpose of receivingPAC applications. An insurance company accesses its E-mail box and findsa waiting list of PAC applications which are subsequently downloaded toGUI-capable computer system 310. In a preferred embodiment as shown inFIG. 3, the GUI-capable computer system 310 advantageously is connectedto the claims management mainframe computer 350 of the insurance company300. Preferably, the GUI-capable buffer computer system 310 is apersonal computer (PC) or a PC server which advantageously can beoperated in parallel with but separate from the insurance company'smainframe computer 350; data, however, beneficially can be interchangedbetween the buffer computer system 310 and the mainframe computer 350.In an exemplary case, as the insurance company 300 applies an insurancecompany document identification number (DIN) to each received PACApplication, the field data contained therein is copied by the buffercomputer system 310 and transmitted to the mainframe computer 350. Seetask T1 b of FIG. 3. Note that, in the exemplary embodiment of thepresent invention when, for example, 350 is a legacy computer componentof a Stage III claims processing system, typically, no changes arerequired in the legacy software application. This is because the AICsoftware module on the buffer 310 is customized for each payer's legacysystem. That is, it transmits to the mainframe only the information thisparticular mainframe was specifically designed to accept.

[0161] Alternatively, the entire PAC application advantageously could becopied by the buffer computer system 310 and downloaded to the mainframecomputer 350, where the image portion of the PAC application then can beremoved from the mainframe's memory. This approach employs basically thesame distribution of information, i.e., text form in the mainframe 350and field data and images in the buffer computer system 310.

[0162] Two things can be gleaned from the above description:

[0163] (1) The information contained in the PAC application isdistributed based on the labeling (i.e., the identity) of the fields.For example, fields containing “attachments” are not sent to the legacymainframe computer.

[0164] (2) There are certain situations where the mainframe 350 willpreviously have been a component in an earlier claims processing system.In these situations, the legacy mainframe computer software will remainunchanged as the transition is made to the current AIC system. This isbecause under the AIC system, the legacy system is only required toaccept the information it was specifically designed to accept. Inaddition, this is true globally. That is, even if legacy mainframes atdifferent insurance companies were designed to accept different forms,the AIC software module at these respective companies is adjusted tomatch the different requirements, i.e., the business rule, i.e.,instruction set, implemented through the specialized software can beadjusted for each individual insurance company.

[0165] In addition, it is worthwhile at this point to summarize the roleof the server computer 310 with its specialized software. The role ofthe server computer (also referred to as the network server), with itsspecialized software, is multifaceted:

[0166] i. act as a digital distribution device. That is, the devicelooks at an incoming file composed of fields. These fields areidentified in some way, e.g., XML schemas, position in the data stream,etc. The device distributes the fields to different computers based onthe identity of these fields, i.e., the filed labels, and a rule fordistribution. Advantageously, as one example, this distribution isdetermined so as to forward to an individual computer only those partsof the file that said computer is capable of handling.

[0167] ii. receives and stores the attachment fields of the PACApplication

[0168] iii. act as a means of viewing the whole PAC Application.

[0169] iv. hosts the application that integrates the distributed partsof the file together on demand of the user.

[0170] The network server with specialized software is but one means ofaccomplishing the result of “distribution of field information.” Anydevice, or combination of devices, exhibiting these features could alsobe used.

[0171] The concept of a digital distribution device that sendsindividual fields of a file, i.e., a collection of fields formed onto aunitary digital structure, to different locations is a novel solution tothe problem of incompatibility of an entire file with a givencomputer-system element. It should also be noted that a digital deviceused to distribute individual fields of a file to different locationsbased on the identity of the fields has never before been described orsuggested. Consequently, the concept of such a digital device is aunique and novel aspect according to the present invention.

[0172] In an exemplary case, this buffer computer 310 is part of a localarea network (LAN) 313, which is connected by high bandwidth cables topersonal computers or other GUI-capable terminals 311, 312 at the desksof the individual reviewing dentists and claims adjusters, respectively.It should be noted that the necessary AIC software has been loaded ontothe server 310, the individual personal computers 311, 312, and themainframe 350. Preferably, once the patient's PAC application has beenreceived, the system's AIC software at either the value-added serviceprovider 500 or the insurance company's computer 310 automaticallynotifies the referring service provider that the PAC application hasbeen received for processing, e.g., using a conventional E-mail message.

[0173] At step S109, the reviewing dentist calls up the graphics portionof the PAC application, in an exemplary case, from the server 310 to apersonal computer 311, each of which is running the appropriate AICsoftware, via the LAN 313 using the assigned DIN. See task T4 in FIG. 3.The reviewing dentist then calls up the text portion of the PACapplication from the mainframe computer 350 using the terminal 351. Itwill be appreciated that the sequence can be reversed at the reviewingdentist's option. It should be noted that some small insurance companiesmay not even require server-LAN 310, 313 system discussed above, butjust a single PC that will incorporate the functions of the elements310, 311, 312, and 313. In any event, the reviewing dentist calls up apatient's PAC application using both his personal computer 311 andterminal 351. When this happens, the system AIC software automaticallygenerates the insurance company's Predetermination Form on one of thetwo screens 311, 351. The installed AIC software advantageously canautomatically transfer whatever information from the PAC application tothe Predetermination form that is useful in completing thePredetermination form, e.g., repetitive information/fields. Forinstance, the service provider's Document Identification Number (PDIN)and the Provider Identification Number (PIN) can be transferredautomatically to the Predetermination form. In addition, the AICsoftware can be written to display the information in the PAC form onthe screen 351 in exactly the way that this particular insurance companywants it displayed.

[0174] In an alternative implementation, a single monitor on thecomputer 311 supporting multiple windows, at least one of which runsterminal emulation software for displaying the output of the mainframecomputer 350, could advantageously be used to display both parts of thePAC application.

[0175] With the AIC system described above, the use of “fields,” thecustomizable claim form, and the placing of coordinated AIC software atboth the service provider's office and the insurance company, haseliminated the need for standardized forms. The result is that eachinsurance company gets exactly the information it wants and has itdisplayed in exactly the way it wants. Thus, the compromise of astandardized claim form as is required with the present NEIC system isavoided.

[0176] In an exemplary case, the reviewing dentist is provided withthree monitors or a large graphics-capable monitor having a multi-pagedisplay mode, on which can be displayed the three pages of the patientfile. It will be appreciated that this configuration is optimized tofacilitate rapid review of the PAC application. The reviewing dentistenters an Insurance Company Document Identification Number (DIN) at thispoint, which number is affixed to all three pages of the patient's file.

[0177] During step S110, the reviewing dentist reviews the PACapplication. More specifically, the review process consists of a reviewof the medical facts or evidence (i.e., the text and x-ray informationin the PAC application), as well as a review of the patient's insurancepolicy. Once the reviewing dentist has made his analysis, he goes to thePredetermination form, i.e., the third page, and enters the requiredinformation to either approve or disapprove the procedure during stepS111. The specific details regarding the information provided by thereviewing dentist will depend on the procedures established at eachindividual insurance company. Either the reviewing dentist or anotherperson, e.g., a claims adjuster, will do the review of the patient'sinsurance policy.

[0178] Advantageously, there are several ways to gain access to thisinformation. First, the server 310 can have information on every policyholder loaded into its memory. Second, the benefits reviewer, i.e.,either the reviewing dentist or the claims adjuster, can have anothermonitor 351, 352 on his desk that is connected to the company mainframecomputer 350. Thus, all that the benefits reviewer must do is select thepatient's insurance ID number and his benefits sheet will appear. Thebenefits reviewer then reads off the information that must be entered inthe Predetermination form and enters the information into the either theGUI-capable computer system 310/311/312 or the mainframe computer 350during step S111. It should again be noted that there is an electronicconnection, in the preferred embodiment, between the mainframe computer350 and the server 310. Whatever information is deemed necessary by thatparticular insurance company to complete the Predetermination form canbe transferred between the mainframe computer 350 and the buffercomputer system 310 by entering data on one of the terminals 311, 351.See, for example, task T5 in FIG. 3.

[0179] At this point, the Predetermination form is ready to be sent tothe referring service provider. When the transmit icon on the computerscreen of the benefit reviewer's GUI-capable computer system 311, forexample, is activated (e.g., by being “clicked” on), the followingsubsteps are automatically performed:

[0180] (a) First, a check is performed to verify that thePredetermination form has been completely and properly filled out. Iferrors are detected, the AIC software notifies the operator via anappropriate annunciator;

[0181] (b) The Predetermination form and the patient's PAC applicationare downloaded to the buffer computer 310. See task T5 a. From thisplatform, the company accesses the on-line service 400 and transmits thePredetermination form, i.e., just the information “fields”, to theservice provider's e-mail address, which is stored in the memory ofserver 310. See task T6. In the AIC software, records are kept as towhich PAC applications have been sent and when and to whom. The properprotocols are used so that when the application reaches the serviceprovider, it arrives there as a computer readable file, i.e., theinformation is stored in “fields” that can be read by the AIC softwareat both the insurance company and the service provider's office;

[0182] (c) A hard copy of the Predetermination form and x-ray areprinted, if desired, by the insurance company, see task T7;

[0183] (d) The complete patient file is archived in the insurancecompany's computer system 310, 340, if desired. See task T8. Otherwise,just the electronic Predetermination form and the PAC application aresaved; and

[0184] (e) The entire three page patient file is now cleared from thereviewing dentist's displays 311, 351 and the AIC software prompts thereviewing dentist as to whether another patient file should be accessed.

[0185] During step S112, the service provider accesses his e-mailaddress with the on-line service 400. All Predetermination forms whichhave been received are automatically delivered to the service provider'scomputer system 210 for insertion into the appropriate patient file. Theservice provider then reviews the Predetermination forms. Uponevaluating the decision of the reviewing dentist, the service providercan either perform the procedure (if approved) or discuss the matterwith the patient's insurance company (if not approved).

[0186] During step S113, the approved procedure is performed by theservice provider. Once the approved procedure has been completed, theservice provider preferably sends in the Final Payment claim (FPC) form.In an exemplary case, this could be as simple as just filling outanother section of the Predetermination form and signing it using theelectronic signature pen, as discussed above. It should be noted that inFIG. 3, this is labeled as P*. Alternatively, if the insurance companyso desires, a separate form just for this purpose can be employed. Thislatter form, which advantageously is the same customizable claim formdiscussed above, is stored in the memory of the provider's computer,must have the Insurance Company's DIN for this particular patient'sprocedure and all other needed information transferred to it, whichadvantageously can all be done by the AIC system software at step S114.At step S115, the Final Payment claim form is transmitted back to theinsurance company. See task T9 of FIG. 3. In an exemplary case,activating the transmit icon on the service provider's computer system210, e.g., by “clicking” on it, automatically results in the executionof the following substeps:

[0187] (a) A check is performed to see that the form has been completelyand correctly filled out. If an error has occurred, the AIC softwarealerts the operator of the detected error;

[0188] (b) A hard copy of the form is printed out, if desired, by theservice provider;

[0189] (c) The complete patient's electronic file is archived in theservice provider's computer system 210, 240. It will be noted again thatthe patient's electronic file can be accessed by patient name, socialsecurity number, document identification number, etc.; and

[0190] (d) The computer system 210 establishes a connection with theon-line service and transmits the patient's Final Payment claim (FPC)form to the insurance company's e-mail address.

[0191] As previously discussed, the AIC software on the serviceprovider's computer system 210 advantageously may include facilities fortransmitting the Final Payment claim form to the insurance company at alater time, e.g., for transmitting all of the days PAC application andFPC forms at one time.

[0192] It will also be noted, as discussed above, that the AIC softwaremaintains records as to which claim form was sent and when it was sentto the insurance company. In an exemplary case, the E-mail address towhich the Final Payment claim form is sent is different from the addressused in transmitting the PAC application. Since the Final Payment claimform does not include a digitized image, i.e., a digitized x-ray, theinsurance company may choose to have the Final Payment claim formdirected to an E-mail address accessible from the mainframe computer350. If the insurance company's processing protocol requires anindependent review of the PAC application, the Predetermination form andthe Final Payment claim form before payment can be authorized, theE-mail address advantageously can be accessed from either the server 310or the mainframe computer 350, since these two computer systems areelectrically coupled at the insurance company 300.

[0193] The insurance company then receives the Final Payment claim formsduring step S1116 when it accesses its Final Payment claim forms mailbox. In an exemplary case, the computer system receiving the FinalPayment claim forms is not the claims management mainframe computer 350of the insurance company but, rather, it is a personal computer orserver 310 that is part of a parallel system having an electronicconnection to the mainframe computer 350. This buffer computer 310advantageously can be part of a LAN 313. The buffer computer 310 isconnected by high bandwidth cables to the personal computers orGUI-capable terminals 312 located at the claims adjusters's desks. Seetask T10. It should again be noted that the appropriate AIC softwaremodules have been loaded onto both the server 310, the personalcomputers 312 and the mainframe computer 350. It will be appreciatedthat the information entered in computer 312 advantageously can beautomatically transferred to the mainframe 350 through the transmissionpath including the computer 312, the buffer computer 310 and theelectronic connection to the mainframe computer 350.

[0194] The Final Payment claim form is then reviewed during step S1117.The adjuster reviewing the Final Payment claim form can, if necessary,call up the PAC application from the memory of the server 310, since theoriginal Insurance Company Document Identification Number for thecorresponding PAC application was transferred to the Predeterminationform and, thus, to the Final Payment claim form. In addition, theadjuster can, if need be, call up the information on the insurancepolicy of the particular patient stored in mainframe computer 350 viaterminal 352. Preferably, the insurance company provides the adjusterwith a separate monitor 352 connected to the claims management mainframecomputer 350.

[0195] Whatever internal paperwork is necessary to be filled out isautomatically downloaded with the Final Payment claim form itself by theappropriate AIC software module. Part of this paperwork will preferablybe form(s) which must be completed so as to order a check issued to theservice provider along with an Explanation of Benefits (EOB). Also atstep S118, whatever information is necessary to be entered into themainframe 350 can be entered directly through the use of the terminal352 or indirectly through computer 312, the buffer computer 310 and theelectronic connection to the mainframe computer 350.

[0196] Finally, upon activating the transmit icon on the insurancecompany's personal computer 312, for example, the following substeps areautomatically executed:

[0197] (a) A check is again preformed to see that the form has beencompletely and correctly completed and the operator is notified if anerror has occurred;

[0198] (b) A hard copy of the form is printed out, if desired by theinsurance company;

[0199] (c) The complete patient file is archived in the insurancecompany's computer system, e.g., on the server. It should again be notedthat the patient file can be accessed using the patient's name, socialsecurity number, or an assigned document identification number, etc.;and

[0200] (d) A payment draft is issued, in the approved amount, to theservice provider. This can be done through any number of methods,including printing a hard copy check and forwarding it through the U.S.postal service, electronic funds transfer, etc. Each form of paymentwill be accompanied with the normal description of the service to whichthese funds should be applied, i.e., the EOB (Explanation of Benefits).

[0201] The preferred embodiment was described as transmitting digitizeddental x-rays as part of an integrated PAC application file transmittedbetween a service provider and an insurance company. However, thepresent invention is broadly directed to the integrated transmission ofany “electronic text form” and any “attachment.” Further, the presentinvention is not limited to transmissions between providers andinsurance companies. Rather, it is intended to facilitate thetransmission of electronic forms with attachments between any person ororganization and any other person or organization.

[0202] For example, the present invention has utility in such otherareas as Property/Casualty Insurance and law enforcement. Thus, the“attachment” need not be an x-ray or other type of image. Rather it canbe any information which is not easily incorporated into an associated“electronic text form” and/or cannot be easily displayed on an existinglegacy computer system. Attachments can include, but are not limited to,pictures, graphs, sound recordings, and nonstandard text. Examples wouldbe x-rays, CTs, MRIs, EKG or EEG recordings, i.e., strip charts,digitized video signals such as Moving Picture Experts Group (MPEG)compressed video signals, transcriptions of Operating Room Notes,estimates for repairs to a house or car, EOBs (Explanation of Benefits),additional ASCII text, and the like. As used in this description, allparticulars regarding a specific “attachment,” such as medicalspecialty, acquiring modality, the patient's problem, etc., can beignored. These are details having absolutely no bearing on the essenceof the present invention. The only requirements are that the informationmust be something that can be digitized and therefore put into the formof a computer file, and that once in this form, it can be “read,reviewed or interpreted” by the person or organization receiving it.

[0203] The exemplary preferred embodiment discussed above addresses onlya stand-alone system of computers, which is independent of the practicemanagement software in the local dentist's office, the claims managementsoftware at each insurance company, and of clearinghouses such as NEIC.However, it will be appreciated that there is an entire spectrum ofdifferent ways to structure a system which will support “attachmentintegrated claims” which will be readily apparent to a person ofordinary skill in the art (after having the benefit of the presentdisclosure), all of which are encompassed by the present invention.

[0204] It should also be noted that the AIC software described thus farhas been independent of the service provider's practice managementsoftware. However, one alternative preferred embodiment calls forintegrating the AIC software with the practice management software. Thiswould further reduce the amount of time spent actually filling out thePAC application and the other paperwork involved in the overall claimsprocess.

[0205] Electronic filing of standard 100% text claims is now beingsupported by many practice management systems and by stand-aloneelectronic claims software systems. In another alternative preferredembodiment, the AIC software could be incorporated into these systems asa means of sending the x-ray part of the PAC application.

[0206] It should also be mentioned that the present invention representsa total solution on three levels to the problem of streamlining theprocessing of insurance claim forms with attachments. First, the systemfrom provider to third party payer is totally digital. The presentinvention includes an integrated system of hardware and AIC softwarethat allows: (1) providers to create an electronic (digital) version ofa patient's PAC application (text and x-ray); (2) providers to transmitthe PAC application to an insurance company; and (3) the insurancecompany to read the patient's PAC application. Thus, it creates acoherent system for the filing, transmission, and processing of “claimswith attachments.”

[0207] Secondly, the present invention is an industry-wide system, whichallows every provider to interface with every third party payer.Finally, the present invention is a system that permits allcommunications between the service provider and the insurance company tobe totally electronic. The present invention makes the entire processelectronic from the initial preparation of the PAC form to the paymentof the final claim. Communication is digital in both directions.

[0208] As discussed above, the patient, the service provider, theinsurance company, or any combination thereof may prefer that allcommunication be performed through a value-added service provider 500.The services performed by the value-added service provider 500advantageously could include any or all of the services listedimmediately below.

[0209] First, the value-added service provider 500 may act as a NationalDental Data Bank (NDDB), i.e., a data bank storing patient dentalimages. Limited information regarding the patient from the PAC form isattached to the digital x-ray to produce a digitized x-ray record. Thisinformation could include, for example, the date that the x-ray wastaken, the identity of the service provider who took the x-ray, thepatient's name and social security number, etc. The digitized x-rayrecord is archived at NDDB for the patient. This would allow theretrieval of the x-ray by the patient at any time for any reason, e.g.,the patient could ask that the x-ray and claim be sent to anotherdentist for a second opinion and/or for a second price estimate. Infact, the patient may request that the PAC application be sent to otherqualified service providers so that they could competitively bid on theneeded procedure.

[0210] In addition to the NDDB function, the value-added serviceprovider 500 could perform prescreening of the PAC applications forerrors and could provide statistics to both the service providers andthe insurance companies regarding, for example, the frequency at which aprocedure is performed or the frequency at which follow up treatment isrequired after a first procedure is performed. The value-added serviceprovider 500 could also do the prior approval review for an insurancecompany or could provide other services tailored to suit the needs ofthe service provider, the patient, and/or the individual insurancecompany.

[0211] It should be mentioned that there are three outside areas ofsoftware that advantageously can be taken into consideration, orignored, with the present invention. These are practice managementsoftware run by the service provider, claims management software run bythe insurance company, and clearinghouse software. The present inventionallows for the entire spectrum of interfacing, from a totallystand-alone system for electronic claims processing to one that is fullyintegrated with practice management software, claims managementsoftware, and the NEIC. Moreover, the present invention is specificallycontrived so that it can be used simultaneously in all modes. That is,one insurance company could choose to have no interfacing between thecomputer 310 running the AIC software and its mainframe computer 350,while, at the same time, another insurance company could choose to haveAIC software running simultaneously on both the mainframe computer 350and the buffer computer system 310. Thus, each operating mode ormethodology could be considered to be a different preferred embodimentof the present invention, notwithstanding the fact that all modes areexpected to be operating simultaneously.

[0212] The present invention was motivated by a desire to solve aproblem which has existed for many years. The AIC software was designedwith this in mind. Thus, for example, redundant information isautomatically moved from one form and file to another along the chain ofoperating steps, i.e., from one document to another within a giveninsurance company's set of forms. Moreover, the AIC softwareadvantageously can be written in C++ or some other appropriateprogramming language. The reason for this is so that when information inentered into areas of the electronic PAC forms, it is entered as a“field.” Being a “field” it can be used as a logic control device, asdiscussed in greater detail above.

[0213] The overall workflow problem to be addressed is treated as acoherent whole. Thus, AIC software is specifically designed so that, ateach step of the preferred operating method, the fact that theinformation is in digital form is used to streamline the process. Thus,the AIC software is designed to eliminate inefficiencies anddeficiencies that exist in current claims handling systems. For example,the information itself can be used as a logical control device and itcan also be transferred from one document to another. It should be notedthat all available forms are written into the AIC software so that theyare coordinated with one another, that is, they know where each has asimilar “field.”

[0214] It should also be noted that the AIC software automates much ofthe overall insurance claims processing, thus eliminating many of theareas that are repetitive or prone to human error. These areas includethe following:

[0215] (a) Filling in the service provider's information. Although eachinsurance company may require something different in the way of serviceprovider information, the AIC software can store consolidated serviceprovider information so that the information need be entered only once.For example, the service provider need only enter his telephone numberonce; the AIC software can reformat this basic information specificallyfor each individual insurance company's form;

[0216] (b) Transmitting the PAC application to the correct e-mailaddress, thus eliminating the errors associated with hand addressing andstamping the mailing envelope;

[0217] (c) Checking each completed form, i.e., PAC application andPredetermination form, for accuracy and completeness, while it is stillat the provider's office or the insurance company; and

[0218] (d) Simultaneously transmitting, archiving, and printing thecompleted forms, e.g., the PAC application.

[0219] It will be appreciated that many such advantages will be evidentto those of ordinary skill in the art from having the requisite PAC formstored in the AIC software on the service provider's computer system210, 240.

[0220] Moreover, the AIC system advantageously can be optimized to limitunnecessary information. For example, the system can make use ofscanners 220 which have portions of their scanning area physically orelectronically masked out, which reduces both scanning time andtransmission time by minimizing the size of the digitized x-rayproduced, for example, during step S104. The provisions for the use ofdigital and digitized signatures also eliminates unneeded papershuffling.

[0221] It should again be noted that the major improvement in efficiencyattributable to the AIC system results from combining or coordinating anelectronic PAC form with an electronic (digitized) x-ray. Thiselectronic x-ray will have a document identification number assigned toit.

[0222] In addition, the AIC system and corresponding method according topreferred embodiments of the present invention provide severalconvenience features which are only possible when using a fullyelectronic filing system. For example, the AIC system facilitatesautomatic acknowledgment by the insurance company that it has receivedthe PAC application. Moreover, the AIC system provides automatictransfer of pertinent information from the PAC application to thePredetermination form. Furthermore, the AIC system components at theinsurance company preferably allow simultaneous viewing of the threedocuments needed to complete the Predetermination form. In addition, theAIC system and requisite software automates the entire transmitting andarchiving processes of the PAC application and the Predetermination format the insurance company.

[0223] In some instances, the electronic reuse of the Predeterminationform as the Final Payment claim form means that the service providerneed only indicate the date that the procedure was performed and enterthe service provider's facsimile or electronic signature. The AICsoftware module at the provider's office requests these be entered intoP, i.e., the Predetermination form, to create P*, i.e., the FinalPayment claim form, and then transmits P* to the final claims e-mailaddress for payment. Moreover, the only information that needs to besent from the service provider to the insurance company is the insurancecompany's assigned document identification number, the date ofcompletion and the service provider's signature.

[0224] The preferred embodiments of the AIC system according to thepresent invention provide dentists in the field with the necessaryhardware and software which allows them to create an electronic(digital) version of a patient's PAC application, both the text and therequired patient x-ray. The AIC software automatically adds these twodata types together to form a single entity, the patient's PACapplication. Moreover, the AIC system provides the insurance companieswith hardware and software which allows them to read the patient'selectronic PAC application. For each insurance company, this applicationis tailored so that it contains the specific information required bythat company and it contains that information in the form required bythat company. As such, the necessity to force standard formats on theinsurance industry is eliminated. Moreover, the AIC system and softwareautomatically attaches a partially filled out Predetermination form tothe patient's PAC application when it is called up for review andapproval. Moreover, the AIC system and software completely eliminatesthe time consuming process of actually handling the patient's film x-rayby insurance company personnel.

[0225] Other modifications to and variations of the invention will beapparent to those skilled in the art from the foregoing disclosure andteachings. Thus, while only certain embodiments of the invention havebeen specifically described herein, it will be apparent that numerousmodifications may be made thereto without departing from the spirit andscope of the invention, as defined in the appended claims.

What is claimed is:
 1. A combination of memories modules storing modulessoftware for converting multiple existing computer systems into aspecial purpose computer system for generating, transmitting, andprocessing attachment integrated files, each of said files containing aplurality of data fields with at least one of said data fieldscontaining a digital attachment, comprising: a first memory disposed inan existing first computer system storing a first legacy softwaremodule, said first legacy software module containing first operatinginstructions readable by said first computer system; a second memorydisposed in an existing second computer system storing a second legacysoftware module, said second legacy software module: containing secondoperating instructions readable by said second computer system, andbeing constructed to process files of specified fields, said fields notcontaining digital attachments, a third software module, accessible bysaid first computer system, said third software module containing thirdoperating instructions readable by said first computer system, a digitaldevice, said digital device operationally connected to said secondcomputer system via a first communications channel, a secondcommunications channel operationally connecting said first computersystem to said digital device for the purpose of transmitting theattachment integrated file from said first computer to said digitaldevice, wherein: the first computer system further comprises: a firstdisplay device for displaying a first form, said first form beinginstantiated by said third software module; a first input devicepermitting entry of first alpha-numeric characters into said first form;and a first processor for converting said first alpha-numeric charactersinto fields to thereby generate first field data, and converting thefirst field data and the digitized data into one of the attachmentintegrated files responsive to said third operating instructions; andthe digital device further comprises: a third memory storing a fourthsoftware module, said fourth software module containing fourth operatinginstructions readable by said digital device system, said fourthsoftware module operating instructions being designed to instruct saiddigital to device to automatically transmit to said second computersystem via said first communications channel those data fields, of anattachment integrated file received from said first computer, that thesecond legacy software module was specifically constructed to process.2. The combination as recited in claim 1, wherein said digital devicefurther comprises: a second input device permitting entry of secondalpha-numeric characters required to complete a second form into saidsecond form, said second form containing a plurality of data fields; asecond display device for displaying said second form and saidattachment integrated file received from said second communicationschannel, said second form being automatically generated when saidattachment integrated file is opened, said second form and saidattachment integrated file being stored in said third memory and atleast a portion of said first alpha-numeric characters in saidattachment integrated file are automatically transferred from saidattachment integrated file to said second form; and a second processorfor converting said second alpha-numeric characters into fields tothereby generate second field data, and generating an outgoing messagecontaining said second field data responsive to said third operatinginstructions.
 3. The combination as recited in claim 1, wherein saidthird software module resides in the memory of said first computersystem
 4. The combination as recited in claim 3, wherein said thirdsoftware module residing on said first computer system is integratedwith said first legacy software module.
 5. The combination as recited inclaim 1, wherein said first software module resides on a r digitaldevice accessible by said first computer system via the Internet.
 6. Thecombination as recited in claim 1, wherein said attachment integratedfile, instantiated by said third software module, is generated by saidfirst computer system, is transmitted to said r digital device via saidsecond communications channel, and the information in specified datafields is digitally entered directly into said second computer system bysaid fourth software module without manual re-entry of said informationof the specified data fields into said second computer system.
 7. Thecombination as recited in claim 1, wherein said specified data fieldsand said attachment data are labeled with the same documentidentification number when said attachment integrated file is receivedby said server.
 8. The combination as recited in claim 1, wherein saidthird software module and said fourth software module are coordinated inthat said fourth software module can identify which fields of saidattachment integrated file generated by said third software module aredata fields to be transmitted to said second computer system and whichfields are attachment fields.
 9. The combination as recited in claim 1,wherein said third software module generates said first form with formatand fields as determined by said second user.
 10. The combination asrecited in claim 1, wherein said digital device is disposed at afacility operated by said second user.
 11. The combination as recited inclaim 1, wherein said fourth software module and said second legacysoftware module are integrated together.
 12. The combination as recitedin claim 1, wherein said third software module and said fourth softwaremodule can be update at the request of said second user.
 13. Thecombination as recited in claim 1, wherein said first computer systemfurther comprises a device for generating the digitized attachment data.14. The combination as recited in claim 13, wherein said device forgenerating the digitized attachment data is a scanner.
 15. Thecombination as recited in claim 1, wherein said first computer systemfurther comprises a device for accepting the digitized data generatedfrom an external source.
 16. The combination as recited in claim 15,wherein said device for accepting the digitized data generated from anexternal source is a CD-ROM drive.
 17. The combination as recited inclaim 1, wherein once the attachment integrated file has been receivedby said-digital device, said digital device or the second computersystem sends an email message to said first user notifying them that thesaid attachment integrated file has been received.
 18. The combinationas recited in claim 1, wherein the attachment data includes one ofpictures, graphs, sound recordings, nonstandard text, x-rays, CTs, MRIs,EKG or EEG recordings, digitized video signals, transcriptions ofOperating Room Notes, estimates for services, Explanation of Benefits(EOBs), and additional ASCII text.
 19. The combination as recited inclaim 1, wherein said first computer system is used to submit claims forservice from a healthcare service provider to a healthcare payer. 20.The combination as recited in claim 1, wherein said first legacysoftware module residing on said first computer system is PracticeManagement Software.
 21. The combination as recited in claim 1, whereinsaid second computer system is disposed at a facility operated by ahealthcare payer's and said second legacy software module is thesoftware used by said payer to process electronic claims submitted byhealthcare providers.
 22. The combination as recited in claim 1, whereinsaid second computer system is the legacy computer system used by ahealthcare payer to process electronic claims submitted by healthcareproviders.
 23. The combination as recited in claim 1, wherein: saidfirst form is a Prior Approval claim form; said digitized datacorresponds to a dental x-ray; and said second form is aPredetermination form.
 24. The combination as recited in claim 1,wherein said first form is a Final Payment claim form.
 25. Thecombination as recited in claim 2, wherein the second form is anExplanation of Benefits (EOB).
 26. The combination as recited in claim1, wherein said second communications channel contains a claims clearinghouse.
 27. A digital device operatively coupled to a computer networkcomprising first and second networked components, the digital devicereceiving a unitary data stream comprising N fields each having arespective Nth field label, and distributing contents of each of the Nfields to one of the first and second networked devices in response tothe N field labels included in the unitary data stream, where N is apositive integer.
 28. The digital device as recited in claim 27, whereinthe digital device receives a plurality of data packets via acommunications channel and assembles the received data packets into theunitary data stream.
 29. The digital device as recited in claim 27,wherein the digital device distributes contents of each of the N fieldsto one of the first and second networked devices in response to Ninstructions generated by the digital device based on an instruction setand the N field labels included in the unitary data stream.
 30. Thedigital device as recited in claim 29, wherein the instruction set isstored on the digital device.
 31. The digital device as recited in claim29, wherein the instruction set is included in the unitary data stream.32. The digital device as recited in claim 27, wherein the digitaldevice is a server responsive to specialized software
 33. The digitaldevice as recited in claim 27, wherein the N field labels followextensible markup language (XML) schemas.
 34. The digital device asrecited in claim 27, wherein the unitary data stream comprises aninsurance claim form.
 35. The digital device as recited in claim 27,wherein N-1 of the N fields contain text data and the Nth one of the Nfields contains a digital attachment.
 36. The digital device as recitedin claim 27, wherein at least two of the N fields include a DocumentIdentification Number (DIN).
 37. The digital device as recited in claim27, wherein each of the N fields includes the same, unique DocumentIdentification Number (DIN), to thereby permit the corresponding unitarydata stream to be reconstructed from outputs of the first and secondnetworked components.
 38. The digital device as recited in claim 27,wherein one of the first and second networked components is a mainframecomputer.
 39. The digital device as recited in claim 38, wherein themainframe computer receives only ones of the N fields containing textdata.
 40. The digital device as recited in claim 27, wherein the digitaldevice communicates with the first and second networked components viathe Internet.
 41. A digital device operatively coupled to a computernetwork comprising first and second networked components, the digitaldevice receiving a unitary data stream comprising N fields arranged in apredetermined order, and distributing contents of each of the N fieldsto one of the first and second networked devices based on thepredetermined order, where N is a positive integer.
 42. The digitaldevice as recited in claim 41, wherein the digital device receives aplurality of data packets via a communications channel and assembles thereceived data packets into the unitary data stream.
 43. The digitaldevice as recited in claim 41, wherein the digital device reads aninstruction set and distributes the contents of each of the N fields toone of the first and second networked devices responsive to theinstruction set.
 44. The digital device as recited in claim 42, whereinthe instruction set is stored on the digital device.
 45. The digitaldevice as recited in claim 42, wherein the instruction set is includedin the unitary data stream.
 46. The digital device as recited in claim41, wherein the digital device is a server responsive to specializedsoftware
 47. The digital device as recited in claim 41, wherein theunitary data stream comprises an insurance claim form.
 48. The digitaldevice as recited in claim 41, wherein at least two of the N fieldsinclude a Document Identification Number (DIN).
 49. The digital deviceas recited in claim 41, wherein each of the N fields includes the same,unique Document Identification Number (DIN), to thereby permit thecorresponding unitary data stream to be reconstructed from outputs ofthe first and second networked components.
 50. The digital device asrecited in claim 41, wherein one of the first and second networkedcomponents is a mainframe computer.
 51. The digital device as recited inclaim 50, wherein the mainframe computer receives only ones of the Nfields containing text data.
 52. The digital device as recited in claim41, wherein the digital device communicates with the first and secondnetworked components via the Internet.
 53. A method for operating adigital device operatively coupled to first and second networkedcomponents, comprising: receiving a unitary data stream including Nfields of data; parsing the unitary data stream to determine a firstportion of the N fields to be routed to the first networked componentand a second portion of the M fields to be routed to the secondnetworked component; and routing the first and second portion of the Nfields to the first and second networked components, respectively, whereN is a positive integer.
 54. The method as recited in claim 53, wherein:the digital device includes a parsing device which parses the unitarydata stream responsive to an instruction set; and the method furthercomprises assembling the unitary data stream from a plurality ofreceived data packets.
 55. The method as recited in claim 54, wherein:the instruction set is incorporated in the unitary data stream; and themethod further comprises extracting the instruction set from the unitarydata stream.
 56. The method as recited in claim 53, wherein the firstnetworked component comprises a mainframe computer
 57. The method asrecited in claim 53, wherein the second networked component instantiatesa graphical user interface (GUI).
 58. The method as recited in claim 53,wherein the digital device comprises a server running specializedsoftware
 59. The method as recited in claim 53, wherein the parsing stepcomprises parsing the unitary data stream in accordance with extensiblemarkup language (XML) schemas to determine a first portion of the Nfields to be routed to the first networked component and a secondportion of the M fields to be routed to the second networked component.59. The method as recited in claim 53, wherein at least two of the Nfields includes a Document Identification Number (DIN).
 60. The methodas recited in claim 53, wherein each of the N fields includes a DocumentIdentification Number (DIN) to thereby permit the unitary data stream tobe reconstructed from respective outputs of the first and secondnetworked components.
 61. The method as recited in claim 53, wherein theunitary data stream comprises an insurance claim form.